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Dietitians of Canada that appropriately planned vegetarian diets
are healthful, nutritionally adequate, and provide health bene\ufb01ts
in the prevention and treatment of certain diseases. Approxi-
mately 2.5% of adults in the United States and 4% of adults in
Canada follow vegetarian diets. A vegetarian diet is de\ufb01ned as
one that does not include meat, \ufb01sh, or fowl. Interest in vege-
tarianism appears to be increasing, with many restaurants
and college foodservices offering vegetarian meals routinely.
Substantial growth in sales of foods attractive to vegetarians
has occurred, and these foods appear in many supermarkets.
This position paper reviews the current scienti\ufb01c data related
to key nutrients for vegetarians, including protein, iron, zinc,
calcium, vitamin D, ribo\ufb02avin, vitamin B-12, vitamin A, n-3
fatty acids, and iodine. A vegetarian, including vegan, diet can
meet current recommendations for all of these nutrients. In
some cases, use of forti\ufb01ed foods or supplements can be help-
ful in meeting recommendations for individual nutrients.
Well-planned vegan and other types of vegetarian diets are
appropriate for all stages of the life cycle, including during
pregnancy, lactation, infancy, childhood, and adolescence.
Vegetarian diets offer a number of nutritional bene\ufb01ts, in-
cluding lower levels of saturated fat, cholesterol, and animal
protein as well as higher levels of carbohydrates, \ufb01ber, mag-
nesium, potassium, folate, and antioxidants such as vitamins
C and E and phytochemicals. Vegetarians have been reported
to have lower body mass indices than nonvegetarians, as well
as lower rates of death from ischemic heart disease; vegetari-
ans also show lower blood cholesterol levels; lower blood
pressure; and lower rates of hypertension, type 2 diabetes,
and prostate and colon cancer. Although a number of feder-
ally funded and institutional feeding programs can accommo-
date vegetarians, few have foods suitable for vegans at this time.
Because of the variability of dietary practices among vegetari-
ans, individual assessment of dietary intakes of vegetarians is
required. Dietetics professionals have a responsibility to support
and encourage those who express an interest in consuming a
vegetarian diet. They can play key roles in educating vegetarian
clients about food sources of speci\ufb01c nutrients, food purchase
and preparation, and any dietary modi\ufb01cations that may be nec-
essary to meet individual needs. Menu planning for vegetarians
can be simpli\ufb01ed by use of a food guide that speci\ufb01es food
groups and serving sizes.J Am Diet Assoc. 2003;103:748-765.
It is the position of the American Dietetic Association and Dietitians of Canada that appropriately planned vegetar- ian diets are healthful, nutritionally adequate, and pro- vide health bene\ufb01ts in the prevention and treatment of cer- tain diseases.
A vegetarian is a person who does not eat meat, \ufb01sh, or fowl or products containing these foods. The eating patterns of vege- tarians may vary considerably. The lacto-ovo-vegetarian eating pattern is based on grains, vegetables, fruits, legumes, seeds, nuts, dairy products, and eggs but excludes meat, \ufb01sh, and fowl. The lacto-vegetarian excludes eggs as well as meat, \ufb01sh, and fowl. The vegan, or total vegetarian, eating pattern is sim- ilar to the lacto-vegetarian pattern, with the additional exclu- sion of dairy and other animal products. Even within these patterns, considerable variation may exist in the extent to which animal products are avoided.
People choosing macrobiotic diets are frequently identi\ufb01ed as following a vegetarian diet. The macrobiotic diet is based largely on grains, legumes, and vegetables. Fruits, nuts, and seeds are used to a lesser extent. Some people following a macrobiotic diet are not truly vegetarian because they use lim- ited amounts of \ufb01sh. Some \u201cself-described\u201d vegetarians, who are not vegetarians at all, will eat \ufb01sh, chicken, or even meat (1,2). Some research studies have identi\ufb01ed these \u201cself-de- scribed\u201d vegetarians as semivegetarians and have de\ufb01ned semi- vegetarian as occasional meat eaters who predominately prac- tice a vegetarian diet (3) or those who eat \ufb01sh and poultry but less than 1 time per week (4). Individual assessment is required to accurately evaluate the nutritional quality of the diet of a vegetarian or someone who says that they are vegetarian.
Common reasons for choosing a vegetarian diet include health considerations, concern for the environment, and animal welfare factors (5,6). Vegetarians also cite economic reasons, ethical con- siderations, world hunger issues, and religious beliefs as their rea- sons for following their chosen eating pattern.
In 2000, approximately 2.5% of the US adult population (4.8 million people) consistently followed a vegetarian diet and af- \ufb01rmed that they never ate meat, \ufb01sh, or poultry (7). Slightly less than 1% of those polled were vegans (7). According to this poll, vegetarians are most likely to live on the east or west coast, in large cities, and to be female. Approximately 2% of 6- to
17-year-old children and adolescents in the United States are vegetarians, and around 0.5% of this age group are vegan (8). According to a 2002 survey (9), about 4% of Canadian adults are vegetarian; this represents an estimated 900,000 people. Factors that may affect the number of vegetarians in the United States and Canada in the future include an increased interest in vegetarianism and the arrival of immigrants from countries where vegetarianism is commonly practiced (10). Twenty to 25% of adults in the United States report that they eat 4 or more meatless meals weekly or\u201cusually or sometimes maintain a vegetarian diet,\u201d suggesting an interest in vegetarianism (11). Additional evidence for the increased interest in vegetarianism includes the emergence of animal rights/ethics courses on col- lege and university campuses; the proliferation of Web sites, magazines and newsletters, and cookbooks with a vegetarian theme; and the public\u2019s attitude toward ordering a vegetarian meal when eating away from home. More than 5% of those surveyed in 1999 said they always order a vegetarian meal when they eat out; close to 60%\u201csometimes, often, or always\u201d order a vegetarian item at a restaurant (12).
Restaurants have responded to this interest in vegetarian- ism. The National Restaurant Association reports that 8 out of 10 restaurants in the United States with table service offer vegetarian entrees (13). Fast-food restaurants are beginning to offer salads, veggie burgers, and other vegetarian options. Many college students consider themselves vegetarians. In re- sponse to this, most university foodservices offer vegetarian options (14).
There has also been a growth in professional interest in veg- etarian nutrition; the number of articles in the scienti\ufb01c litera- ture related to vegetarianism has increased from less than 10 articles per year in the late 1960s to 76 articles per year in the 1990s (15). In addition, the main focus of the articles is chang- ing. Twenty-\ufb01ve or more years ago, articles primarily had themes questioning the nutritional adequacy of vegetarian di- ets. More recently, the theme has been the use of vegetarian diets in the prevention and treatment of disease. More articles feature epidemiological studies, and fewer reports are case studies and letters to the editor (15).
There is a growing appreciation for the bene\ufb01ts of plant- based diets, de\ufb01ned as diets that include generous amounts of plant foods and limited amounts of animal foods. The American Institute for Cancer Research and the World Cancer Research Fund call for choosing predominantly plant-based diets rich in a variety of vegetables and fruits, legumes, and minimally pro- cessed starchy staple foods and limiting red meat consumption, if red meat is eaten at all (16). The American Cancer Society recommends choosing most food from plant sources (17). The American Heart Association recommends choosing a balanced diet with an emphasis on vegetables, grains, and fruits (18), and the Heart and Stroke Foundation of Canada recommends using grains and vegetables instead of meat as the centerpiece of meals (19). The Uni\ufb01ed Dietary Guidelines developed by the American Cancer Society, the American Heart Association, the National Institutes of Health, and the American Academy of Pediatrics call for a diet based on a variety of plant foods, in- cluding grain products, vegetables, and fruits to reduce risk of major chronic diseases (20).
The US market for vegetarian foods (foods like meat analogs, non- dairy milks, and vegetarian entrees that directly replace meat or other animal products) was estimatedto be $1.5 billion in 2002, up
from $310 million in 1996 (21). This market is expected to nearly double by 2006 to $2.8 billion(21). Canadian sales of meat analogs more than tripled between 1997 and 2001 (22).
The ready availability of new products, including forti\ufb01ed foods and convenience foods would be expected to have a marked impact on nutrient intake of vegetarians. Forti\ufb01ed foods such as soymilks, meat analogs, juices, and breakfast cereals can add substantially to vegetarians\u2019 intakes of calcium, iron, zinc, vitamin B-12, vitamin D, and ribo\ufb02avin. Vegetarian convenience foods including veggie burgers and veggie dogs, frozen entrees, meals in a cup, and soymilk can make it much simpler to be a vegetarian today than in the past.
Vegetarian foods are readily available, both in supermarkets and in natural foods stores. About half of vegetarian foods vol- ume is sold through supermarkets and about half through nat- ural foods stores (21). Three-fourths of soymilk sales take place in supermarkets (21).
ents.\u201d They give recommendations on meeting nutrient re- quirements for those who choose to avoid all or most animal products. Some have said that implementation of the Dietary Guidelines can best be achieved by use of vegetarian and plant- rich diets (24). National food guides include some vegetarian options. Foods commonly eaten by vegetarians such as le- gumes, tofu, soyburgers, and soymilk with added calcium are included in a table accompanying the USDA\u2019s Food Guide Pyr- amid (23). Canada\u2019s Food Guide to Healthy Eating can be used by lacto and lacto-ovo-vegetarians (25). Health Canada has stated that well-planned vegetarian diets are supportive of good nutritional status and health (26).
Vegetarian diets offer a number of advantages, including lower levels of saturated fat, cholesterol, and animal protein and higher levels of carbohydrates,\ufb01ber, magnesium, boron, folate, antioxidants such as vitamins C and E, carotenoids, and phyto- chemicals (27-30). Some vegans may have intakes for vitamin B-12, vitamin D, calcium, zinc, and occasionally ribo\ufb02avin that are lower than recommended (27,29,31).
Plant protein can meet requirements when a variety of plant foods is consumed and energy needs are met. Research indicates that an assortment of plant foods eaten over the course of a day can pro- vide all essential amino acids and ensure adequate nitrogen reten- tion and use in healthy adults, thus complementary proteins do not need to be consumed at the same meal (32).
Estimates of protein requirements of vegans vary, depending to some degree on diet choices (33). A recent metaanalysis of nitro- gen balance studies found no signi\ufb01cant difference in protein needs due to the source of dietary protein (34,35). Based primar- ily on the lower digestibility of plant proteins, other groups have suggested that protein requirements of vegans may be increased by 30% to 35% for infants up to the age of 2 years, 20% to 30% for 2- to 6-year-old children, and 15% to 20% for those 6 years and older, in comparison with those of nonvegetarians (36).
digestibility corrected amino acid score (PDCAAS), which is the standard method for determining protein quality, isolated soy protein can meet protein needs as effectively as animal protein, whereas wheat protein eaten alone, for example, may be 50% less usable than animal protein (37). Nutrition care professionals should be aware that protein needs might be higher than the RDA in vegetarians whose dietary protein sources are mainly those that are less well digested, such as some cereals and legumes.
Cereals tend to be low in lysine, an essential amino acid. This may be relevant when evaluating diets of individuals who do not consume animal protein sources and are relatively low in protein (35). Dietary adjustments such as the use of more beans and soy products in place of other protein sources that are lower in lysine or an increase in dietary protein from all sources can ensure an adequate intake of lysine.
Although some vegan women have protein intakes that are mar- ginal, typical protein intakes of lacto-ovo-vegetarians and of veg- ans appear to meet and exceed requirements (29). Athletes can also meet their protein needs on plant-based diets (38,39).
Plant foods contain only nonheme iron, which is more sensitive than heme iron to both inhibitors and enhancers of iron absorp- tion. Inhibitors of iron absorption include phytate; calcium; teas, including some herb teas; coffee; cocoa; some spices; and
vegetables can enhance iron absorption and can help to reduce effects of phytate (41-43). Studies show that iron absorption would be signi\ufb01cantly reduced if a diet were to be high in in- hibitors and low in enhancers. Recommended iron intakes for vegetarians are 1.8 times those of nonvegetarians because of lower bioavailability of iron from a vegetarian diet (44).
The main inhibitor of iron absorption in vegetarian diets is phytate. Because iron intake increases as phytate intake in- creases, effects on iron status are somewhat less than might be expected. Fiber appears to have a minor effect on iron absorp- tion (45,46). Vitamin C, consumed at the same time as the iron source, can help to reduce the inhibitory effects of phytate (42,43), and some research links high vitamin C intake to im- proved iron status (47,48). The same is true for organic acids in fruits and vegetables (41). The higher intakes of vitamin C and of vegetables and fruits by vegetarians can favorably impact iron absorption (2). Some food preparation techniques such as soaking and sprouting beans, grains, and seeds can hydrolyze phytate (49-51) and may improve iron absorption (42,51,52). Leavening of breads hydrolyzes phytate and enhances iron ab- sorption (49-51,53,54). Other fermentation processes, such as those used to make soy foods like miso and tempeh, may also make iron more available (55), although not all research sup- ports this. Whereas many studies of iron absorption have been short term, there is evidence that adaptation to low intakes takes place over the longer term and involves both increased absorption and decreased losses (56,57). It is likely that iron needs will depend on the make up of the overall diet and be signi\ufb01cantly lower for some vegetarians than for others.
Studies typically show iron intake by vegans to be higher than that of lacto-ovo-vegetarians and of nonvegetarians, and most studies show iron intake by lacto-ovo-vegetarians to be higher than that of nonvegetarians (29). Iron sources are shown in the Table. Incidence of iron de\ufb01ciency anemia among vegetarians is similar to that of nonvegetarians (29,31,58). Al- though vegetarian adults have lower iron stores than nonveg-
Because phytate binds zinc, and animal protein is believed to enhance zinc absorption, total zinc bioavailability appears to be lower on vegetarian diets (63). Also, some vegetarians have diets that are signi\ufb01cantly below recommended intakes for zinc (27,29,64,65). Although overt zinc de\ufb01ciency has not been seen in Western vegetarians, the effects of marginal intakes are poorly understood (66). Zinc requirements for vegetarians whose diets are high in phytate may exceed the RDA (44). Zinc sources are shown in the Table.
Compensatory mechanisms may help vegetarians adapt to lower intakes of zinc (65,67). Some food preparation tech- niques, such as soaking and sprouting beans, grains, and seeds as well as leavening bread, can reduce binding of zinc by phytate and increase zinc bioavailability (49,50,68).
Calcium is present in many plant foods and forti\ufb01ed foods (see Table). Low-oxalate greens (bok choy, broccoli, Chinese/Napa cabbage, collards, kale, okra, turnip greens) provide calcium with high bioavailability (49% to 61%), in comparison with cal- cium-set tofu, forti\ufb01ed fruit juices, and cow\u2019s milk (bioavailabil- ity in the range of 31% to 32%) and with forti\ufb01ed soymilk, sesame seeds, almonds, and red and white beans (bioavailabil- ity of 21% to 24%) (69-71). Figs and soy foods such as cooked soybeans, soy nuts, and tempeh provide additional calcium. Calcium-forti\ufb01ed foods include fruit juices, tomato juice, and breakfast cereals. Thus, various food groups contribute dietary calcium (72,73). Oxalates present in some foods can greatly reduce calcium absorption, so vegetables that are very high in these compounds, such as spinach, beet greens, and Swiss chard, are not good sources of usable calcium despite their high calcium content. Phytate may also inhibit calcium absorption. However, some foods with high contents of both phytate and oxalate, such as soy foods, still provide well-absorbed calcium (71). Factors that enhance calcium absorption include ade- quate vitamin D and protein.
Calcium intakes of lacto-vegetarians are comparable with or higher than those of nonvegetarians (74,75), whereas intakes of vegans tend to be lower than both groups and often below recommended intakes (27,31,71,75). Diets high in sulfur-con- taining amino acids may increase losses of calcium from bone. Foods with a relatively high ratio of sulfur-containing amino acids to protein include eggs, meat,\ufb01sh, poultry, dairy prod- ucts, nuts, and many grains. There is some evidence that the impact of sulfur-containing amino acids is only important with low calcium intakes. Excessive sodium intake may also pro- mote calcium losses. In addition, some studies show that the ratio of dietary calcium to protein is more predictive of bone health than calcium intake alone. Typically, this ratio is high in lacto-ovo-vegetarian diets and favors bone health, whereas vegans have a calciumto protein ratio that is similar to or lower than that of nonvegetarians (71,76).
All vegetarians should meet the recommended intakes for calcium, established for their age group by the Institute of Med- icine (77). This can be accomplished, in nonpregnant, nonlac- tating adults, by consuming at least 8 servings per day of foods that provide 10% to 15% of the Adequate Intake (AI) for cal- cium, as indicated in the Vegetarian Food Guide Pyramid and Vegetarian Food Guide Rainbow (72,73). Adjustments for
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